Minnesota Health Care Programs (MHCP) covers personal care assistance (PCA) services provided to children and youths with disabilities in the least restrictive environment so they may attend school and receive a Free Appropriate Public Education (FAPE) just as children and youth without disabilities. MHCP and schools are required to follow FAPE.

MHCP will only reimburse for the federal share of the cost of school-based PCA services when the services are identified in the child or youth’s Individualized Education Program (IEP) plan or Individualized Family Services Plan (IFSP). The PCA services must be medically necessary; and provided by a qualified personal care assistant who is trained and supervised by a qualified licensed health-related service professional (Minnesota Statutes,148 – Public Health Occupations), or trained and supervised by a special education teacher with the core skills for licensure (Minnesota Rules, 8710.5000).

Note: IEP refers to both the IEP and IFSP in the remainder of this manual.

Eligible Providers

To provide PCA services, an individual must meet all the following requirements:

· Completion of the required training (refer to Required PCA Training for more information)

· Received training and supervision from a qualified professional (QP) on how to meet the child’s or youth’s needs

· Be at least 18 years of age

· Be able to effectively communicate with the child or youth

· Be able to effectively communicate with the QP who is providing training and supervising the health-related PCA services that the child or youth receives during the school day

· Be able to effectively provide PCA services according to the child’s or youth’s PCA plan of care

· Be able to appropriately respond to the child’s or youth’s needs and immediately report significant changes in the child’s or youth's condition to the supervising QP

· Have to the ability to maintain required daily written records including, but not limited to, PCA activity checklists or logs, and communication with the QP and emergency contacts

· Be employed by the school district to provide PCA services or be under contract with an agency that has a PCA service agreement with the district

Required PCA Training

To provide IEP PCA services, the personal care assistant must complete the following training activities:

· View and complete the online Minnesota Department of Human Services (DHS) support workers training and test.

· To take the training and test, go to the Personal Care Assistance and Community First Services and Supports Training and Tests webpage.

· Select the test titled PCA/CFSS support workers: Individuals who help people with daily tasks in either PCA or CFSS (or current CSG workers)

· Submit a certificate of completion of training to the school or employing agency. The personal care assistant should also keep a copy of the completion certificate.

· Refer to More Information on the PCA and CFSS Training and Tests webpage for more questions.

· Complete training and orientation given by the QP on the specific needs of the individual child or youth as identified in the IEP and written in the PCA plan of care.

· Be aware of the other support services provided for the child or youth.

· Be knowledgeable about the PCA plan of care and emergency procedures before performing services.

· Display competency in providing the required service according to the child or youth’s plan of care.

· Understand and use the processes the QP identifies to report changes in the child or youth’s condition or behaviors to the appropriate person.

· Understand the documentation requirements for the services provided.

Note: The procedures, tasks or activities that a personal care assistant performs must fall within the scope of practice or professional responsibilities of the QP who is training and supervising the personal care assistant. All paraprofessional work or assistance is not health related. Paraprofessionals that meet the requirements to provide PCA services must be able to identify the difference between health-related and educational services.

Eligible Members

To be eligible for PCA services a student must meet the following criteria:

· Be determined eligible for Medical Assistance

· Have medical services identified in a student's individualized education program and be eligible for services as determined in Minnesota Statues, 256B.0625, subdivision 26.

Covered Services

· Activities of daily living

· Health-related procedures and tasks

· Observation and redirection for behaviors or symptoms where there is a need for assistance.

· Behaviors that require assistance at least four times per week include:

· Level 1 behaviors that require the immediate response of another person.

· Increased vulnerability due to cognitive deficits.

· Elopement, verbal aggression and socially inappropriate behavior

· Increased need for assistance for students who are verbally aggressive or resistive to care so that the time needed to perform activities of daily living is increased.

Note: A personal care assistant may observe and redirect the child or youth for episodes where there is a need for redirection because of behaviors. Training of the personal care assistant must be based on the needs of the recipient, the PCA services care plan, and any other support services provided.

Definitions

Activities of daily living (ADLs) include health and hygiene needs that are part of daily living, as well as activities integral to the activity (for example, cleaning up spills, laundering soiled clothing and cleaning up toileting accidents). ADLs include the following:

· Bathing: Assistance with basic personal hygiene and skin care

· Dressing: Assistance with choosing, putting on and changing clothing and with application of special appliances, wraps or clothing

· Eating: Assistance with hand washing and applying orthotics required for eating, as well as transfers and feeding

· Grooming: Assistance with basic hair care, oral care, shaving, applying cosmetics and deodorant; ensuring clothes are clean and properly fastened; and care of eyeglasses and hearing aids (confirming batteries work, positioning aids). Nail care is included, except for a child or youth who has diabetes or poor circulation

· Mobility: Assistance with ambulation, including use of a wheelchair. Mobility does not include providing transportation for a child or youth

· Positioning: Assistance with positioning or turning a child or youth for necessary care and comfort

· Toileting: Assistance with bowel or bladder elimination and care, including transfers, mobility, positioning, feminine hygiene, use of toileting equipment or supplies, cleansing the perineal area, inspection of the skin and adjusting clothing

· Transfers: Assistance with transferring the child or youth from one seating or reclining area to another

Dependency in activities of daily living means a person requires hands-on assistance or constant supervision and cueing to accomplish one or more of the ADLs every day, or on the days the activity is performed. However, a child or youth is not considered dependent in an ADL if an adult would perform the activity for the child or assist them with the activity because of the child’s age and the assistance needed is age appropriate.

Elopement refers to leaving a classroom or school building without permission or supervision, fleeing from staff and wandering without supervision.

Health-related procedures and tasks are related to the specifically assessed health needs of a student that can be taught or assigned by a state-licensed healthcare or mental health professional and performed by a personal care assistant. These services include, but are not limited to

· Range of motion and passive exercise to maintain a child or youth's strength and muscle function.

· Assistance with self-administered medication, including reminders to take medication, bringing medication to the child or youth, and assistance with opening medication containers, including medications given through a nebulizer. A personal care assistant must not determine the medication dose or time for medication.

· Interventions for seizure disorders that occur more than two times per week and require physical assistance to maintain safety

· Procedures for complex health-related needs, including tracheostomy suctioning, services to a child or youth needing ventilator support and other direct cares are covered PCA services if delegated, trained and supervised by a registered nurse. Additionally, these service can only be offered if they can be fully and safely completed by the personal care assistant, training is specialized and individualized to the needs of the child or youth, and delegation and training are documented.

Level 1 behaviors are defined as follows:

· Physical aggression toward self (self-injurious behaviors)

· Physical aggression toward others (physical injury to others)

· Destruction of property

A child or youth qualifies for PCA services if they demonstrate one or more of the behaviors listed under Level 1 behavior examples that are determined to occur daily, or are episodic and ongoing (for example, occurring four times a week).

Level 1 behavior examples

Self-injurious	Physical injury to others	Destruction of property
Hitting	Hitting	Breaking windows, lamps or furniture
Biting oneself	Biting	Tearing clothes
Head banging	Pinching	Setting fires
Burning oneself	Scratching	Using tools or objects to damage property
Self-poking or stabbing	Kicking
Ingesting foreign substances
Pulling out hair
Suicide threats

The IEP team will assign a personal care assistant to intervene if a current, but infrequent (fewer than four times per week or fewer than one time a day), level 1 behavior is identified in the IEP plan and requires an immediate response of another person to redirect the physical aggression. Medical Assistance (MA) will pay for the response time. The time allowed is when the personal care assistant is fully engaged, working face-to-face or hands-on with the child or youth.

Socially inappropriate behavior refers to aggressive behavior, inappropriate physical contact, verbal outbursts, noncompliance with rules and lack of personal boundaries

Verbal aggression refers to threats, bullying, insulting, shouting or derogatory language that disrupts the school environment and creates intimidation for staff and peers

Once a child or youth qualifies for PCA services, they may also receive assistance from a personal care assistant for redirection or intervention during a behavioral episode; increased vulnerability due to cognitive deficits; socially inappropriate behaviors and other delegated health-related procedures and tasks.

Noncovered Services

· Services by a personal care assistant, or a substitute for the personal care assistant, who is not determined to be qualified by the school or not trained and supervised by a QP.

· Services provided by a parent, stepparent, paid legal guardian or foster parent.

· Services provided in the home of the child or youth, except during the time they are learning from home as identified by their IEP.

· Care requiring a trained registered nurse or other trained medical professional. Care examples include, but are not limited to, reinserting g-tubes, sterile procedures, giving injections, administering medication, and nurse assessments either delegated or provided by someone who is not a nurse.

· Hearing aid check (programming such as setting and resetting volume, calibrating or making other adjustment)

· Services provided to a child or youth that would reasonably require assistance because of their age.

· Helping a child or youth with school assignments and class activities or redirecting, cueing and intervening to help a child stay on task to complete school assignments, projects or activities.

· Continuous monitoring or observing of a child or youth who might run away when there is no reasonable opportunity to elope (for example, in a classroom setting where a teacher and paraprofessional are present).

· Continuous monitoring or observing of a child or youth who may have a behavioral episode that occurs infrequently.

· Monitoring and assisting the child or youth to perform assigned “jobs” at school, job training or coaching or vocational services.

· Services provided to a child or youth as a before and after school activity, including sports, clubs, class projects, tutoring, music lessons and child care.

· Activities that teach anything, including teaching a child to grocery shop, manage finances or get around in the community by taking buses

· Instrumental activities of daily living described in Minnesota Statutes, 256B.0659

· Monitoring juvenile offenders to prevent harm to others or inappropriate behavior

· Restraining a child or youth, applying restraints or monitoring a child or youth placed in isolation or time-out

· Vehicle driver services used to transport eligible members

· Bus monitor services

· Babysitting, child care or homemaker services

· Mental health behavioral aid services provided by a personal care assistant

Documentation

To be eligible for MHCP payment, state and federal regulations require schools to maintain fiscal records that support the nature and extent of health-related service they provide to children and youths eligible for services under the Individuals with Disability Education Act (IDEA).

Review the documentation requirements in Record Keeping and Documentation under the IEP section of the MHCP Provider Manual.

The school must maintain required documentation listed in this section and have it readily available for periodic submission to MHCP or the Minnesota Department of Education for interim rates. It is the responsibility of the school to determine where the documentation is maintained and that it is readily available.

Documentation may be web-based, electronic or paper records.

PCA Time Studies

Effective July 1, 2018, MHCP will allow schools to use the “average times” documented in a recent time study when billing for PCA services.

A PCA time study is a report that documents the average daily time per day it takes to perform each daily task based on a 10-day time study. A PCA time study is completed by the personal care assistant. To be considered a recent time study, the QP or supervisor must review the time study with the school annually and update it at least every two years, unless the care plan needs to be updated more frequently.

PCA time studies should be:

· Created based on the location and the services identified in the IEP or the current plan of care

· Performed by a trained personal care assistant who has or will work with the child or youth throughout the school day

· Conducted over a 10-day period with each task or behavior episode documented. The documentation should include the start and end times for each task or behavior episode.

After the 10-day study is complete, schools must calculate the average daily time for each task, and the total daily time for all PCA services.

Include the following in the PCA time study documentation:

· School information

· Student information

· Name, signature and initials of the service providers who provided the PCA service during the time study

· Date

· Task information

· Initials of the person or persons providing the service

· Number of children or youths in the group if more than one child is receiving the same task at the same time (shared care)

· Average daily time for each the task

If the child or youth leaves school early on any given day, reduce the average daily time for that task by the percent of services not provided.

If the child or youth is absent from school, enter “absent” in the activity field and report 0 for time. Do not bill MA.

Bill MA 1 unit using procedure code T1019.

For annual data reporting, document the total amount of time identified and documented in the PCA activities checklist.

PCA Plan of Care

A PCA plan of care is a written description of each of the medically necessary PCA services a child or youth will need during the school day with specific instruction of how the services should be provided. The PCA plan of care must be developed by a QP working within their scope of practice.

The PCA plan of care may be included in the IEP or provided as a separate document. In either situation, the PCA plan of care must be specific to the location where the special education is provided and to the needs of the child or youth. Additionally, the plan of care must include enough detail to describe how each service should be provided.

· Initial completion: the PCA plan of care must be completed within the first week of starting PCA services.

· Updates: Update the PCA plan of care when there is a change in the need for PCA services.

· Review: Review the plan of care annually.

Required Components
The PCA plan of care must include the following:

· Start and end date of the plan of care

· Child’s or youth’s name, student identification number, date of birth, demographic information including name of parent, guardian or responsible party, and emergency contact information

· List of special instructions or procedure required to meet the child’s or youth’s specific requests or needs, such as meeting their communication needs due to a language barrier or whether they or their family has requested a personal care assistant of a specific gender

· A clear summary including the diagnosis, condition, sign or symptom that is creating the need for the service

· Identify the covered services the child or youth will need

· Steps to address safety and vulnerability issues of the child or youth, including but not limited to, responding to immediately predictable, identifiable triggers to level 1 behavior episodes

· Date, name and signature of the QP

Note: a copy of the most current PCA plan of care or the child’s or youth’s IEP must be immediately available to the person who is providing the PCA services.

Activities Checklist

The IEP Services Personal Care Assistance Activities Checklist (DHS-4122C) (PDF) offers two methods for how to report PCA activities. Schools may report using one of the following methods:

· Actual Time – Report the actual time for each daily task using a start and end time for each covered PCA services provided in a day.

· Time Study – Report the average daily time per day based on a 10-day time study.

Follow the prompts on the IEP Services Personal Care Assistance Activities Checklist (DHS-4122C) (PDF) to complete the form.

Supervision

Professional Qualifications

The qualifications for a person providing supervision of a personal care assistant are based on the service provided, license, certification, scope of practice, professional responsibilities, and professional experience of the supervisor.

A qualified professional (QP) may include but is not limited to:

· Audiologist

· Licensed school psychologist

· Licensed school social worker

· Mental health professionals

· Occupational therapist

· Physical therapist

· Professional nurse

· Special education teacher

· Speech language pathologist

Duties of the QP

A QP must supervise anyone providing PCA services through use of direct training, observation, return demonstrations and consultation with school staff, the child or youth, and the parent or guardian of the child or youth.

The QP trains and supervises the person providing PCA services and evaluates the effectiveness of the services.

The QP must do the following:

· Confirm that the personal care assistant meets the qualifications to provide the services

· Appropriately assign tasks to the personal care assistant

· Provide training and ensure competency of the personal care assistant in meeting the individual needs of the child or youth before services are provided

· Verify that the PCA plan of care is based on the needs of the child or youth as described in their IEP plan; and completed within the first week after the start of services and updated as needed

· Review the personal care assistant’s documentation of services provided

· Document training, communication, initial and periodic evaluations of the PCA services, and what actions are needed to improve services provided by the personal care assistant

QP Evaluations and Supervision Visits

Initial Evaluation

The QP must complete an initial evaluation of the personal care assistant through direct observation of their work within the first 14 days (or sooner as determined by the QP) of starting to provide regularly scheduled services to the child or youth.

After the initial evaluation, subsequent visits do not require direct observation of each person providing PCA services unless determined by the QP based on the needs of the child or youth and the personal care assistant’s ability to meet those needs.

Periodic Evaluations

The QP must complete periodic evaluations as follows:

· At least every 90 days during the first year of the child or youth receiving PCA services

· After the first two 90-day evaluations (total of 180 days) of a personal care assistant providing service to the same child or youth, the supervisory visits may alternate between unscheduled phone or internet technology and in-person visits, unless the in-person visits are needed according to the plan of care.

· Every 120 days during the second and succeeding years that the same personal care assistant is providing PCA services to the same child or youth.

Conduct evaluations more often if:

· The QP determines more evaluations are necessary based on the needs of the child or youth or the personal care assistant’s ability to meet those needs

· The child or youth, parent or guardian, teacher, IEP case manager or other educator makes a request for increased supervision of the PCA services

· The PCA plan of care requires more frequent evaluations

Note: the QP must sign, date and indicate the supervision visit on the PCA activity checklist when a periodic evaluation and supervision visit is conducted during the period identified on the activity checklist.

Documentation of Supervision Visit

At the initial and each periodic supervision visit, the QP must evaluate whether the PCA services:

· Meet the needs of the child or youth as identified in the IEP or IFSP

· Help the child or youth participate in and benefit from regular and special education

The QP evaluation must include review and documentation of the following:

· Satisfaction level of the child or youth and parent or guardian with the PCA services

· Adequacy of the tasks and activities in the PCA plan of care to meet the needs of the child or youth

· The personal care assistant’s understanding of the child’s or youth’s needs; knowledge of the plan of care; when to notify the QP of concerns or changes in the condition or behavior of the child or youth; and when emergency actions and contacts are required

· The personal care assistant’s demonstrated ability to competently carry out the tasks and activities to meet the needs of the child or youth as trained

· Documentation by the personal care assistant of the services provided, the personal care assistant’s communication with the QP and emergency contacts made, if any

· Changes in the needs of the child or youth requiring change in the level of service, revision of the PCA plan of care or additional training of the person providing PCA services

At the conclusion of the evaluation, the QP must document the previously listed information and the following:

· Actions necessary to correct any deficiencies in the work of a person providing PCA services, actions taken and timeline for actions planned

· Hands-on training or individualized training for the care of the child or youth that was conducted or assignments and timeline for training to occur

· Revision of the PCA plan of care as necessary to meet the needs of the child or youth

Billing

Bill MA 1 unit using procedure code T1019.

Submit claims using the 837P Professional claim type. Refer to the IEP section of the MN–ITS User Manual for step-by-step instructions for direct data entry claims. Batch billers submitting X12 837P claims may review the MHCP 5010/D.0 Compliance webpage and the AUC Minnesota Uniform Companion Guide for transaction guidelines.

MHCP is the payer of last resort for all other liable parties except school districts. Bill MHCP for covered IEP services (except transportation and PCA services) only after receiving payment or a denial of coverage from all other liable health care plans.

IEP PCA services are not covered by private health care plans; therefore, it is not necessary to obtain a denial of coverage for these services before billing MHCP.

Retain copies of all correspondence with private health plans regarding determinations for IEP services coverage, including phone conversations for five years.

Billing for PCA Services

Use place of service 12 (home) when the child or youth is learning from home and the medically necessary health-related IEP PCA services are identified in the child’s or youth’s IEP.

Review IEP Billing and Authorization Requirements for general billing requirements.

Legal References

Minnesota Statutes, 256B.0625, subdivision 26 (Covered Services – Special education services)
Minnesota Statutes, 256B.0625, subdivision 19(c) (Covered Services – Personal care)
Minnesota Statutes, 256B.0659 (Personal Care Assistance Program)
Minnesota Statutes, 148 (Public Health Occupations)
Minnesota Rules, chapter 8710 (Teacher and Other School Professional Licensing) (see 8710.5000 – 6300)
Minnesota Statutes, 125A.08(c)(1-3) (Individual Education Programs – paraprofessionals)
Minnesota Statutes, 125A.21 (Third-Party Payment)
Minnesota Statutes, 125A.74 (Medical Assistance Payments to School Districts)

Report this page

Issue:
Email:
Comments: